Provider Demographics
NPI:1225807191
Name:WATSON, MADELINE (RD)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:VYLETEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1222 BISHOP RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1144
Mailing Address - Country:US
Mailing Address - Phone:313-506-2922
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133VN1401X
133VN1401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1401XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric Critical Care